Sexual-offending behavior need not be intractable, at least when
treatment follows a complete and thorough assessment, including
endocrinological tests and a psychosexual history.
FIG1Though often difficult, it
is possible to reduce the risk of sexual-offending behavior with psychiatric
treatment, only through careful assessment, accurate diagnosis, and use of
Fabian Saleh, M.D. recommends the use of testosterone-lowering
medications for sexual offenders with pedophilia.
This was the message delivered by Fabian Saleh, M.D., at the annual meeting
of the American Academy of Psychiatry and the Law in Chicago last October.
Saleh is medical director of the Sexual Disorders Clinic at UMassMemorial
Community Healthlink. He is also an assistant professor of psychiatry in the
Law and Psychiatry Program and the Child and Adolescent Psychiatry Division at
UMass Memorial Medical Center and director of research at the Baltimore-based
National Institute for the Study, Prevention, and Treatment of Sexual
The term “sexual offender” is a legal, not medical, construct,
he noted, and psychiatrists should use their expertise to determine what may
be motivating the sexually deviant behavior and then use evidence-based
treatments to reduce the risk of recidivism.
A subcategory of people who have committed sexual crimes may have a type of
paraphilia, such as pedophilia, exhibitionism, or voyeurism, he said, noting
that paraphilias are underreported psychiatric disorders.
In addition, some people who sexually offend may do so partly due to
symptoms of an underlying psychiatric illness such as bipolar disorder,
antisocial personality disorder, or attention-deficit/hyperactivity
Deviant sexual behaviors may also be influenced by the presence of a
neuropsychiatric or neurological disorder, such as a brain tumor or lesion,
“According to the literature, about 10 percent to 20 percent of
children have been molested by age 18,” he said. “Although one
should not equate child molestation with pedophilia, one can certainly make
the argument that a certain percentage of this cohort (that is, child
molesters) may have offended because of an underlying paraphilic disorder
(that is, pedophilia). Similarly, about 20 percent of adult females have been
the targets of people with exhibitionism. These and similar data suggest that
a certain percentage of sex offenders may indeed have an underlying paraphilic
Aside from reducing the risk for future sexual-offending behavior, the goal
of treatment for sexual offenders with comorbid psychiatric illness or
paraphilia is to improve their quality of life by decreasing their distress,
increasing their autonomy, and reintegrating them into society.
It is possible for people who offend sexually to have more than one type of
paraphila, Saleh pointed out, or to have paraphilia and a comorbid psychiatric
disorder, often including conduct disorder, attention-deficit/hyperactivity
disorder, bipolar disorder, or schizophrenia. The sexual misconduct may be a
symptom of an underlying psychiatric or neurological disorder, according to
People who commit sexual offenses usually display “global patterns of
behavior problems,” Saleh noted, which may manifest themselves through
isolated or impulsive problem sexual behaviors such as exposing oneself or
time-limited, reactive patterns of oversexualized behavior.
Saleh advises psychiatrists evaluating individuals who have committed
sexual offenses to conduct an in-depth assessment for psychiatric problems,
neurological disorders, and risk of violence.
When interviewing sexual offenders, psychiatrists should be aware that
denial can be a major obstacle, he continued. The interview should include
taking a psychosexual history to gather information on deviant and nondeviant
sexual behaviors and relationships. Phallometric assessments are often useful
in learning more about what factors are involved in the subject's sexual
Also, psychiatrists should collect collatoral information from a variety of
sources, including significant others, police reports, victims, and probation
or parole officers.
In addition, Saleh recommends obtaining a complete endocrinological
evaluation that includes hormonal and hematological tests.
Saleh noted that cognitive-behavioral therapy (CBT) focusing on prevention
of deviant sexual behaviors can also be a useful part of treatment. With
regard to sexually deviant behavior, CBT operates on the idea that“
paraphilias are maintained by distorted cognitions and reinforced by
masturbation and inappropriate fantasy.” For instance, CBT may be used
to challenge distorted thoughts and beliefs surrounding the subject's deviant
Developing strategies that help patients anticipate and resist deviant
sexual urges and replacing maladaptive behaviors with more functional
behaviors may also be helpful when working with people who have offended
Sometimes, Saleh said, behav ioral therapy may be helpful in treating
sexual offenders. The goal of the therapy is to extinguish deviant sexual
arousal through a set of techniques such as systematic desensitization,
aversion therapy, and biofeedback.
When certain symptoms are not ameliorated by psychotherapeutic
interventions, or when cravings for deviant sexual acts become overpowering,
pharmacotherapy may be indicated, Saleh said.
Testosterone-lowering medications can be helpful in reducing deviant sexual
urges, but only appear to do so in people with pedophilia. These include
luteinizing hormone-releasing agonists, medroxyporgesterone acetate, and
cyproterone acetate. “Antiandrogens and hormone-reducing medications
decrease in a very short time the frequency and intensity of symptoms related
to pedophilia,” Saleh said.
Selective serotonin-reuptake inhibitors (SSRIs) may be indicated in sexual
offenders with a paraphilic disorder and comorbid depression or anxiety
because they may cause sexual dysfunction in some patients while ameliorating
depression and anxiety symptoms.
However, while there is evidence that SSRIs may cause sexual dysfunction in
some who take them, “almost all SSRI-related sexual dysfunction data
derive from studies involving male and female patients afflicted with
depressive and anxiety disorders and not paraphilias,” Saleh pointed
In addition, they may not reduce a person's sexual urges, but simply
interfere with sexual arousal and/or orgasm, which wouldn't necessarily stop a
sexual offender from reoffending, Saleh noted. That is why he recommended
their use only for sexual offenders with anxiety and depression.
“Once we thoroughly assess the subject, it is important to use
evidence-based treatment to reduce deviant sexual urges,” Saleh